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Wednesday Jul 31, 2019

Where Do You Draw the Line With Patients, Animals?

Woof. Has air travel literally gone to the dogs?

[dog in airport terminal]

After an emotional support dog recently bit an American Airlines flight attendant(www.cnn.com) -- whose wound required stitches -- the flight attendants' union called for stricter standards for emotional support animals. And the union wasn't alone.(www.foxnews.com)  

According to Forbes,(www.forbes.com) more than 80% of Americans surveyed think ESAs should be allowed on commercial airplanes, but nearly half of respondents said it is too easy to get a doctor's note for an ESA, and nearly three-fourths think some people exploit the ESA loophole to avoid pet carrier fees.

Before the dog-bite incident, American had clarified(dfw.cbslocal.com) which animals passengers can bring on board and which they cannot. (Note to Samuel L. Jackson fans: There are no snakes allowed on planes.)

United Airlines made news last year when it prevented an emotional support peacock from boarding a flight.(www.washingtonpost.com) Meanwhile, a man in Philadelphia has certified a pet alligator as an ESA.(www.inquirer.com) School will be starting soon, and a growing number of ESAs will be living in college dorms.(www.inquirer.com)

So, where does one draw the line? We asked our new physician bloggers how they handle patient requests regarding writing letters for their pets. Here is what they shared.

Offering Alternatives

As family physicians, we are often asked to evaluate a patient's condition to determine whether they qualify for a range of services or exemptions. Our patients bring these requests in earnest, believing that we will agree with their own assessment of their needs, yet it is our responsibility to be objective in how we reach our conclusions before we sign our names.

A common request is for a letter in support of an ESA for housing or plane rides. Although I consider each request, I am always cognizant of the possible effect my patient's request will have on others around them and how to balance these needs.

When my elderly patient who had been living in her car for several months with her cat finally found a place to live, she was devastated when she learned of the property's no-pet policy. Knowing this cat had been a reason she didn't commit suicide while she was experiencing homelessness (she couldn't bear the thought of what would happen to her cat), I understood the importance of keeping this pair together.

But not all cases are so clear; I have been asked by a new patient with no history of mental health concerns for a letter that would allow the patient's dog on an upcoming flight. This may be an effective, nonpharmacologic way to address a recently developed anxiety about flying, but what if they then sit next to someone who is deeply afraid of or allergic to dogs? Is this, in fact, the best treatment we can offer?

Although it may seem like a gray area to navigate, I have found using the Diagnostic and Statistical Manual of Mental Disorders as a starting point to be helpful. I talk to my patients about the symptoms they are experiencing, what it means to be appropriately diagnosed, and how to manage their symptoms beyond just my letter. I offer counseling if they aren't already engaged in this aspect of care and review meditation and mindfulness options. And together, we create a followup plan to monitor how they're doing. This approach has enabled me to not only feel holistic about caring for the support they need, but also to say no (while offering alternatives) when I am not comfortable with a patient's request.

Margaux Lazarin, D.O., M.P.H., Redwood City, Calif.

Balancing Patients' Needs

Although I have pets, I would not describe myself as an animal person. I find people who take their animals everywhere rather annoying. However, I realize that I can't project my own preferences onto my patients, and I don't feel it is appropriate to deny them access to something that they think is helpful.

I personally use exercise to help me deal with stress. Running is what keeps me balanced, and it is what I look forward to each day. But for many people it is something else, and they may not be able to exercise due to chronic medical problems or disabilities. Working in a rural area, I see a lot of isolation, and unfortunately, sometimes a pet is the only viable option for companionship for people without transportation. I have seen people develop depression and anxiety without their animals. So, although it isn't something I would choose, I do appreciate the impact animals have on my patients' well-being.

I have one pediatric patient with a progressive chronic disease who requested a companion dog. I also have one patient who brings her leash-trained lizard to the office -- which makes other patients rather uneasy in the waiting room -- yet without it, she may not show up for an appointment.

This is where I think we get into trouble with negotiating one patient's needs over another's. People deserve autonomy, and a doctor's office is one of the spaces where people sometimes have to tolerate others' needs or behaviors. One patient may be screaming while another is having an emotional response to someone screaming. One patient may have on too much perfume while another has an asthma attack as a result. Our goal is to serve everyone who seeks our care. And just as I respect the person who needs the lizard or the perfume, I also try to accommodate the scared or the wheezing individual by getting everyone out of the waiting room and into exam rooms as quickly as possible.

Kimberly Becher, M.D., Clay, W.Va.

Just Say No

What is a service animal, anyway? I had no idea. I really didn't.

I thought I had a good grasp on it and that it was clear: Service animals were those dogs who stoically walked alongside their owner -- their charge, really -- doing tasks such as guiding an owner who is blind or assisting with mobility for an owner using a wheelchair. They would sit under tables in restaurants with a harness that boldly declared "DO NOT PET" because, after all, they were working.

Now I can't recognize a service animal, and here's why: As far as I can tell (and I invite corrections here), protections put in place both in the Americans with Disabilities Act and policies within Housing and Urban Development were written with enough flexibility that almost any dog (or miniature horse weighing approximately 70-100 pounds) can ostensibly be claimed as a support animal. As the Department of Justice points out,(www.ada.gov) untrained support animals and service animals are not the same, but there is a growing number of people who appear to be relying on their pets.

And here's where I come in as a doctor: Many people ask for notes documenting that their pet is, in fact, a service animal. I just can't do it. I can see that my patients love their pets and that they want them around -- including places where they'd otherwise be banned (think restaurants, flights, some apartments, etc.). But unless your animal -- your dog or miniature pony -- is trained to do a specific task to help manage your disability as a working animal and not just a pet, I can't do it.

Because, simply, that means your dog is not a service animal. (Even if it's really cute and emotionally supportive. Sorry.)

Allison Edwards, M.D., Kansas City, Kan.

Implement a Pet Policy

We've had enough requests from patients for letters regarding ESAs that our practice is developing a policy on how to handle such requests. Patients often request letters so they can keep their pets in public housing or rental properties. My trouble with these requests is this: Aren't all pets ESAs? If we really think about it, this is why we own pets.

I did have one patient with congestive heart failure whose well-trained dog would notify other family members when his owner was not doing well, but in most cases, a note from me seems like merely an excuse to keep their ordinary pet in the type of housing they live in or to bypass the added fees incurred by owning a pet.

I can appreciate how a pet can serve an important role in aiding someone through depression and anxiety, but the downstream ramifications of labeling them as an ESA are not clear. For example, does an ESA that is authorized by a physician become a "treatment?" Will we then be expected to prescribe ESAs for patients who ask for them?

Luis Garcia, M.D., York, Pa.

More on Housing

Although I have not yet had any unusual requests, there are rumors at my clinic of a patient who once brought a miniature pony to an office visit, and I have a couple of patients who bring dogs to every visit. Also, at a nursing home that I frequent, there is a companion dog who is either a resident of the facility or an intermittent guest.

I typically get one to two requests a month from patients for letters endorsing their need to keep their dog or cat as an ESA. In most cases, this is because a landlord is requiring documentation to allow a patient to keep the specified pet in their residence.

As a clinic policy, we do not write letters specifically stating that an animal is certified as an emotional support companion unless a patient has already gone through the legal process to do so. As a result, most of my letters are fairly vague and generic.

My standard letter is as follows: "To whom it may concern: X is a patient of mine who has expressed a desire to keep [specified pet] as an emotional support animal. It is my impression that allowing [patient] to do so would help provide much-needed emotional and psychological support. The loss of this animal could potentially be emotionally and psychologically detrimental to this patient. Please consider allowing [patient] to keep the specified pet as a companion animal, as requested. Feel free to contact my office with any further concerns."

Kurt Bravata, M.D., Buffalo, Mo.

Posted at 02:53PM Jul 31, 2019 by Margaux Lazarin, D.O., M.P.H.

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